Chapter 33 Medical-Surgical Nursing: Coronary Artery Disease and Acute Coronary Syndrome

2. Which individuals would the nurse identify as having the highest risk for CAD? a. A 45-year-old depressed male with a high-stress job b. A 60-year-old male with below normal homocysteine levels c. A 54-year-old female vegetarian with elevated high-density lipoprotein (HDL) levels d. A 62-year-old female who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m2

a. A 45-year-old depressed male with a high-stress job The 45-year-old depressed male with a high-stress job is at the highest risk for CAD. Studies demonstrate that depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels actually help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m2 depicts normal weight, and thus the patient with two risk factors is at greatest risk for developing CAD.

7. When planning emergent care for a patient with a suspected MI, what should the nurse anticipate administrating? a. Oxygen, nitroglycerin, aspirin, and morphine b. Oxygen, furosemide (Lasix), nitroglycerin, and meperidine c. Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen d. Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

a. Oxygen, nitroglycerin, aspirin, and morphine The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other medications may be used later in the patient's treatment.

3. When providing nutritional counseling for patients at risk for CAD, which foods would the nurse encourage patients to include in their diet (select all that apply)? a. Tofu b. Walnuts c. Tuna fish d. Whole milk e. Orange juice

a. Tofu b. Walnuts c. Tuna fish Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.

1. The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which ethnic group would the nurse select as the highest priority for this intervention? a. White male b. Hispanic male c. African American male d. Native American female

a. White male The incidence of CAD and myocardial infarction (MI) is highest among white, middle-aged men. Hispanic individuals have lower rates of CAD than non-Hispanic whites or African Americans. African Americans have an earlier age of onset and more severe CAD than whites and more than twice the mortality rate of whites of the same age. Native Americans have increased mortality in less than 35-year-olds and have major modifiable risk factors such as diabetes.

5. After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? a. "I will replace my nitroglycerin supply every 6 months." b. "I can take up to five tablets every 3 minutes for relief of my chest pain." c. "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." d. "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

b. "I can take up to five tablets every 3 minutes for relief of my chest pain." The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or one metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of three doses and contact EMS if symptoms have not resolved completely.

14. The patient comes to the ED with severe, prolonged angina that is not immediately reversible. The nurse knows that if the patient once had angina related to a stable atherosclerotic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? a. Unstable angina b. Acute coronary syndrome (ACS) c. ST-segment-elevation myocardial infarction (STEMI) d. Non-ST-segment-elevation myocardial infarction (NSTEMI)

b. Acute coronary syndrome (ACS) The pain with ACS is severe, prolonged, and not easy to relieve. ACS is associated with deterioration of a once-stable atherosclerotic plaque that ruptures, exposes the intima to blood, and stimulates platelet aggregation and local vasoconstriction with thrombus formation. The unstable lesion, if partially occlusive, will be manifest as unstable angina or NSTEMI. If there is total occlusion, it is manifest as a STEMI.

6. The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply)? a. Flushing b. Ashen skin c. Diaphoresis d. Nausea and vomiting e. S3 or S4 heart sounds

b. Ashen skin c. Diaphoresis d. Nausea and vomiting e. S3 or S4 heart sounds During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds.

9. The nurse is providing teaching to a patient recovering from an MI. How should resumption of sexual activity be discussed? a. Delegated to the primary care provider b. Discussed along with other physical activities c. Avoided because it is embarrassing to the patient d. Accomplished by providing the patient with written material

b. Discussed along with other physical activities Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed.

4. Which antilipemic medications should the nurse question for a patient with cirrhosis of the liver (select all that apply)? a. Niacin (Nicobid) b. Ezetimibe (Zetia) c. Gemfibrozil (Lopid) d. Atorvastatin (Lipitor) e. Cholestyramine (Questran)

b. Ezetimibe (Zetia) d. Atorvastatin (Lipitor) Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently and the medication stopped if these enzymes increase. Niacin's side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use.

12. The nurse is examining the ECG of a patient who has just been admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? a. Sinus tachycardia b. Pathologic Q wave c. Fibrillatory P waves d. Prolonged PR interval

b. Pathologic Q wave The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

15. In caring for the patient with angina, the patient said, "I walked to the bathroom. While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, but the pain is gone now." What further assessment data should the nurse obtain from the patient? a. "What precipitated the pain?" b. "Has the pain changed this time?" c. "In what areas did you feel this pain?" d. "Rate the pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine."

c. "In what areas did you feel this pain?" Using PQRST, the assessment data not volunteered by the patient is the radiation of pain, the area the patient felt the pain, and if it radiated. The precipitating event was going to the bathroom and having a bowel movement. The quality of the pain was "like before I was admitted," although a more specific description may be helpful. Severity of the pain was the "worst chest pain ever," although an actual number may be needed. Timing is supplied by the patient describing when the pain occurred and that he had previously had this pain.

10. Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for what common complication? a. Dehydration b. Paralytic ileus c. Atrial dysrhythmias d. Acute respiratory distress syndrome

c. Atrial dysrhythmias Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days following CABG surgery. Although the other complications could occur, they are not common complications.

20. The nurse assesses the right femoral artery puncture site as soon as the patient arrives after having a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. What should the nurse do next to ensure the femoral artery is intact? a. Palpate the insertion site for induration. b. Assess peripheral pulses in the right leg. c. Inspect the patient's right side and back. d. Compare the color of the left and right legs.

c. Inspect the patient's right side and back. The best method to determine that the right femoral artery is intact after inspection of the insertion site is to logroll the patient to inspect the right side and back for retroperitoneal bleeding. The artery can be leaking and blood is drawn into the tissues by gravity. The peripheral pulses, color, and sensation of the right leg will be assessed per agency protocol.

16. The patient is being dismissed from the hospital after ACS and will be attending rehabilitation. What information does the patient need to be taught about the early recovery phase of rehabilitation? a. Therapeutic lifestyle changes should become lifelong habits. b. Physical activity is always started in the hospital and continued at home. c. Attention will focus on management of chest pain, anxiety, dysrhythmias, and other complications. d.Activity level is gradually increased under cardiac rehabilitation team supervision and with ECG monitoring.

d. Activity level is gradually increased under cardiac rehabilitation team supervision and with ECG monitoring. In the early recovery phase after the patient is dismissed from the hospital, the activity level is gradually increased under supervision and with ECG monitoring. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the first phase of recovery, activity is dependent on the severity of the angina or MI, and attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. With early recovery phase, the cardiac rehabilitation team may suggest that physical activity be initiated at home, but this is not always done.

13. For which problem is percutaneous coronary intervention (PCI) most clearly indicated? a. Chronic stable angina b. Left-sided heart failure c. Coronary artery disease d. Acute myocardial infarction

d. Acute myocardial infarction PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and CAD are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure, such as left-sided heart failure.

8. When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food choice? a. Baked flounder b. Angel food cake c. Baked potato with margarine d. Canned chicken noodle soup

d. Canned chicken noodle soup Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.

11. A patient was admitted to the emergency department (ED) 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). What complication of MI should the nurse anticipate? a. Unstable angina b. Cardiac tamponade c. Sudden cardiac death d. Cardiac dysrhythmias

d. Cardiac dysrhythmias The most common complication after MI is dysrhythmias, which are present in 80% of patients. Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

17. A patient experienced sudden cardiac death (SCD) and survived. What should the nurse expect to be used as preventive treatment for the patient? a. External pacemaker b. An electrophysiologic study (EPS) c. Medications to prevent dysrhythmias d. Implantable cardioverter-defibrillator (ICD)

d. Implantable cardioverter-defibrillator (ICD) An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used but are not the best prevention of SCD.

18. A female patient who has type 1 diabetes mellitus has chronic stable angina that is controlled with rest. She states that over the past few months she has required increasing amounts of insulin. What goal should the nurse use to plan care that should help prevent cardiovascular disease progression? a. Exercise almost every day. b. Avoid saturated fat intake. c. Limit calories to daily limit. d. Keep Hgb A1C less than 7%.

d. Keep Hgb A1C less than 7%. If the Hgb A1C is kept below 7%, this means that the patient has had good control of her blood glucose over the past 3 months. The patient indicates that increasing amounts of insulin are being required to control her blood glucose. This patient may not be adhering to the dietary guidelines or therapeutic regimen, so teaching about how to maintain diet, exercise, and medications to maintain stable blood glucose levels will be needed to achieve this goal.

19. A male patient who has coronary artery disease (CAD) has serum lipid values of LDL cholesterol 98 mg/dL and HDL cholesterol 47 mg/dL. What should the nurse include in the patient teaching? a. Consume a diet low in fats. b. Reduce total caloric intake. c. Increase intake of olive oil. d. The lipid levels are normal.

d. The lipid levels are normal. For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40mg/dL. His normal lipid levels should be included in the patient teaching and encourage him to continue taking care of himself. Assessing his need for teaching related to diet should also be done.